Train noise survey

Your contact information:

First name:

Last name: _______________________________________________

Address:

Postal code: _____________________

Phone:

E-mail: ___________________________________________________

Date of event:_____________________

Date of event:_____________________

Date of event:_____________________

Time: _______________

Time: _______________

Time: _______________

Disturbances:

Disturbances:

Disturbances:

(DD/MM/YYYY)

(AM/PM)

(DD/MM/YYYY)

(AM/PM)

(DD/MM/YYYY)

(AM/PM)

Loud noises
Vibration
Trains passing
Locomotives running slowly
Use of whistles, bells, or horns
Train cars clashing together
Wheels scraping against rails
Motor noises

Loud noises
Vibration
Trains passing
Locomotives running slowly
Use of whistles, bells, or horns
Train cars clashing together
Wheels scraping against rails
Motor noises

Loud noises
Vibration
Trains passing
Locomotives running slowly
Use of whistles, bells, or horns
Train cars clashing together
Wheels scraping against rails
Motor noises

Other (specify): ___________________

_________________________________

Other (specify): ___________________

_________________________________

Other (specify): ___________________

_________________________________

Effects:
Disturbed sleep
Difficulty carrying on a
conversation
Unable to use outdoor areas
Babies start crying
Difficulty concentrating

Effects:
Disturbed sleep
Difficulty carrying on a
conversation
Unable to use outdoor areas
Babies start crying
Difficulty concentrating

Effects:
Disturbed sleep
Difficulty carrying on a
conversation
Unable to use outdoor areas
Babies start crying
Difficulty concentrating

Other (specify): ___________________

__________________________________

Other (specify): ___________________

__________________________________

Other (specify): ___________________

__________________________________

How often has this occurred?

How often has this occurred?

How often has this occurred?

____________________

____________________

____________________

Thank you for your answers!

Print, fill out, and mail without a stamp to:

Tyrone Benskin
MP for Jeanne-Le Ber
House of Commons
Ottawa ON K1A 0A6